Provider Demographics
NPI:1467508812
Name:OBERLY, JON RICHARD (O D)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:RICHARD
Last Name:OBERLY
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:965 STEWART ST
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-1800
Mailing Address - Country:US
Mailing Address - Phone:304-599-8380
Mailing Address - Fax:
Practice Address - Street 1:2500 MEADOWBROOK MALL
Practice Address - Street 2:JC PENNEY OPTICAL
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-9792
Practice Address - Country:US
Practice Address - Phone:304-842-8515
Practice Address - Fax:214-427-2588
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV619OD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVT32544Medicare UPIN
WVOB9161253Medicare ID - Type Unspecified